Instant Access Colonoscopy Insurance Verification

This form was created to help you verify your insurance benefits.

This form needs to be completed in its ENTIRETY (prior to your prep appointment), or we will not bill your insurance for the procedure, and you will be expected to pay up front.

Our colorectal surgeons are now preferred with Cigna, Aetna, and Premera

Please have the following information available when calling your insurance company:

Insurance Company Name

Insurance Company Phone Number (on back of your card)

Patient Name

Date of Birth

Policy Holder Name

Date of Birth

ID Number

Name of representative you talked to

Date & Time

Our information is the following:

Alaska Colorectal Surgery 2751 DeBarr Road, Suite 280 Anchorage, AK 99508

TAX ID: 92-0177040

June M. George, M.D. - NPI: 1891735346; Kerrie R. Bossard, M.D. - NPI: 1548267032; Daniel C. Rossi, D.O. - NPI: 1568660835

I understand that the above is an estimate only. I understand that I am financially responsible for any balances, after insurance pays, and that they must be paid within 10 days. Full payment will be required at the time of pre-op appointment, if this form is not completed in its ENTIRETY.

Signature of Patient/Legal Guardian

Date

** Screening/Routine Colonoscopy - most insurance companies will not cover under age 50

Please be advised that the CPT code and cost above are only for SCREENING COLONOSCOPY, if a polyp or other condition is found, your procedure and diagnosis code will change. This will deem your colonoscopy MEDICAL and other benefits may apply.

Some other CPT/ICD-10 codes to check on (in case it becomes medical):

Procedure Code (CPT): 45380

Cost of my procedure: $2300.00

Possible diagnosis (ICD-10): D12.0-D12.9 (specific code is dependent on location of neoplasm found

Procedure Code (CPT): 45385

Cost of my procedure: $2671.00

Possible diagnosis (ICD-10): D12.0-D12.9 (specific code is dependent on location of neoplasm found

2. What is my yearly deductible? Per Individual $:

Per Family $

3. How much of the deductible has been met this year? Individual $:

Family $:

4. What is my out of pocket maximum?

Has it been met?

5. What is my co-insurance level?

6) Is a pre-certification required for this procedure?

Yes No

If yes, # to call:

7. Ask if your claims will be paid at the preferred rate? Please tell your insurance company that Alaska Colorectal Surgery is the only group of colorectal specialists in Alaska.

Yes No

If no, ask for a benefit exception so that your claims will be paid at the preferred rate.

I understand that as a policyholder with AETNA, it is required to obtain a benefit Deficit PRIOR to my treatment

8. For some services, insurance carriers state they will pay 100% of usual and customary. Please secure the amount your insurance carrier will pay based on our office not being a preferred provider:

9. Ask for a reference once your call is completed. Reference #:

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